Effect of narrow paravisceral aorta on target vessel instability after fenestrated and branched endovascular aortic repair.

To investigate the effect of narrow paravisceral aorta (NPA) on target vessel instability (TVI) after fenestrated-branched endovascular aortic repair. We conducted a single-center retrospective study (2014-2023) of patients treated by fenestrated-branched endovascular aortic repair for thoracoabdominal aortic aneurysms (TAAA) or pararenal aortic aneurysms. The paravisceral aorta was defined as the aortic segment limited by the diaphragmatic hiatus proximally and the emergence of lower renal artery distally, and was considered "narrow" in case of a minimum inner diameter of <25 mm. The minimum aortic diameter, location, longitudinal extension, angulation, calcification, and thrombus thickness of NPA were evaluated at the preoperative computed tomography angiogram. End points were 30-day technical success and freedom from TVI. There were 142 patients with JRAA/pararenal aortic aneurysm (n = 85 [59%]) and extent IV (n = 24 [17%]) or extent I-III (n = 33 [23%]) TAAA, with 513 target arteries successfully incorporated through a fenestration (n = 294 [57%]) or directional branch (n = 219 [43%]). A NPA was present in 95 patients (70%), 73 (86%) treated by fenestrated endovascular aortic repair (FEVAR) and 22 (39%) by branched endovascular aortic repair (BEVAR). The overall 30-day mortality was 2% and technical success was 99%, without differences between NPA and non-NPA (P = .99). Kaplan-Meier estimated freedom from TVI at 4 years was 82%, 81% (95% CI, 75-95) in patients with a NPA and 80% (95% CI, 68-94) and in those without NPA (P = .220). The result was maintained for both FEVAR (NPA: 81% [95% CI, 62-88]; non-NPA: 76% [95% CI, 60-99]; P = .870) and BEVAR (NPA: 77% [95% CI, 69-99]; non-NPA: 80% [95% confidence interval (CI) 66-99]; P = .100). After multivariate analysis, the concomitant presence of a NPA <20 mm and angulation of >30° was significantly associated with TVI in FEVAR (HR, 3.21; 95% CI, 1.03-48.70; P = .036), being the result mostly driven by target vessel occlusion. In BEVAR, a NPA diameter of <25 mm was not associated with TVI (HR, 2.02; 95% CI, 0.59-5.23; P = .948); after multivariate analysis, the use of outer branches in case of a NPA longitudinal extension of >25 mm (hazard ratio [HR], 3.02; 95% CI, 1.01-36.33; P = .040) and NPA severe calcification (HR, 1.70; 95% CI, 1.00-22.42; P = .048) were associated with a higher chance for TVI. FEVAR and BEVAR are both feasible in cases of NPA and provide satisfactory target vessels durability. The use of outer branches should be avoided in cases with an inner aortic diameter of <25 mm with a longitudinal extension of >25 mm or moderate to severe NPA calcifications. In FEVAR, bridging stent patency may be negatively influenced by NPA of <20 mm in association with aortic angulation of >30°.

Piazza M ，Squizzato F ，Forcella E ，Bilato MJ ，Colacchio EC ，Grego F ，Antonello M ... -  《-》

Outcomes using inverted iliac limb bifurcate components in fenestrated/branched endografting.

The use of standard bifurcate pieces in fenestrated/branched endovascular aortic repair (F/BEVAR) requires adequate length from the lowest branch or fenestration to the aortic bifurcation. In patients with prior aortic surgery, the aortic bifurcation is often artificially established in a more proximal position, compromising the infrarenal length, which hinders the placement of a standard bifurcate component below the fenestrated/branched component. Short bifurcate bodies using an inverted contralateral limb have been purpose-built to address this challenge. However, reported outcomes for this device remain limited, with specific concerns about the durability of the inverted iliac limb sealing region. We sought to evaluate outcomes of F/BEVAR using an investigational inverted iliac limb bifurcate, manufactured by Cook Medical. This study was a retrospective review of prospectively maintained data from the US-Aortic Research Consortium from 2005 to 2022. Patients were included if they underwent F/BEVAR for thoracoabdominal or complex abdominal aortic aneurysms. Patients were excluded if they did not have a bifurcate device placed. Patients were then compared based on the use of an inverted iliac limb or standard bifurcate component. The primary outcome for this study was technical success. Secondary outcomes included 30-day mortality, freedom from ischemic leg complications, freedom from type I endoleaks (TIELs), freedom from type II endoleaks (TIIELs), freedom from type III endoleaks (TIIIELs), and graft component separations. A total of 1944 patients met study criteria with 442 (22.8%) inverted iliac limb bifurcates and 1502 (77.2%) standard bifurcates. Patients who received inverted iliac limbs were more likely to have had prior aortic surgery (63.8% vs 28.5%; P < .001). Patients receiving inverted iliac limbs had longer procedure times (265 minutes; interquartile range [IQR], 201-342 minutes vs 241 minutes; IQR, 186-313 minutes; P < .001), more contrast use (89 mL [IQR, 55-135 mL] vs 109 mL [IQR, 75-156 mL]; P < .001), and higher estimated blood loss (250 mL [IQR, 150-500 mL] vs 250 mL [IQR, 110-400 mL]; P = .042). There were no differences in rates of technical success (97.3% vs 96.1%; P = .310), rates of endoleaks upon completion of the case (18.0% vs 21.4%; P = .123), or 30-day mortality rates (1.8% vs 2.5%; P = .466) between patients receiving inverted iliac limb and standard bifurcated components. There were no differences in cumulative survival, freedom from limb ischemia, freedom from aneurysm rupture, and freedom from TIIIELs over the course of 5 years between patients receiving inverted bifurcates and standard bifurcated components. Patients with inverted iliac limb bifurcate components had decreased freedom from reinterventions, TIELs, and TIIELs. After adjustment for potential confounders, the use of an inverted iliac limb was not associated with reinterventions (hazard ratio,1.044; 95% confidence interval, 0.849-1.285; P = .682). There was a total of 2 component separations (0.1%) of the bifurcate component from the fenestrated/branched component over the study period, both of which occurred in the standard bifurcate components. The use of investigational inverted iliac limb bifurcate components is a safe option with favorable mid-term outcomes in patients who are not anatomical candidates for standard bifurcate components. Patients undergoing investigational inverted iliac limb bifurcate component implantation had decreased freedom from reinterventions, which likely corresponds with the complexity of repair associated with them.

Khoury MK ，Beck AW ，Farber MA ，Gasper W ，Lee WA ，Oderich G ，Parodi FE ，Schanzer A ，Schneider D ，Sweet M ，Timaran CH ，Eagleton MJ ... -  《-》

The impact of large aneurysm diameter on the outcomes of thoracoabdominal aneurysm repair by fenestrated and branched endografts.

Aim of the study was to analyse the impact of preoperative thoracoabdominal aneurysm diameter on the outcomes of fenestrated/branched endografting. Patients who underwent endovascular thoracoabdominal repair at 2 European centres (2011-2021) were analysed. Median diameter was calculated; the third quartile was considered a cut-off. Outcomes were compared in 2 groups based on the diameter value. Primary endpoints were technical success, spinal cord ischaemia and 30-day/in-hospital mortality. Survival, freedom from reintervention and target visceral vessels instability were follow-up outcomes. Out of 247 thoracoabdominal aortic aneurysms, the median diameter was 65 mm, first quartile was 57 mm; third quartile was 80 mm, set as cut-off value. Fifty-nine (24%) patients had diameter ≥80 mm. Custom-made and off-the-shelf branched endograft were used in 160 (65%) and 87 (35%), respectively. Technical success was 93% (<80 mm: 91% vs ≥80 mm: 94%; P = 0.47). Twenty-three (9%) patients had spinal injury (<80 mm: 7% vs ≥80mm: 17%; P = 0.03). Twenty-two (9%) patients died within 30-day/in-hospital (<80 mm: 7% vs ≥80 mm: 15%; P = 0.06). Multivariate analysis did not report preoperative diameter ≥80 mm as significant risk factor for primary endpoints. The median follow-up was 13 (interquartile range: 2-37) months and at 3-year survival and freedom from reintervention rates were 65% and 62%, respectively. After univariate and multivariate analyses, preoperative diameter ≥80 mm was considered an independent risk factor for reinterventions [hazard ratio (HR): 1.9; 95% confidence interval (CI) 1.1-3.6; P = 0.04], and for target visceral vessels instability (HR: 3.1; 95% CI: 1.3-5.1; P = 0.04), occurred in 45 (18%) cases. However, after competing risk methods, preoperative diameter did not show significance for follow-up results. A preoperative thoracoabdominal aortic aneurysm diameter >80 mm has not had a direct impact on early technical and clinical outcomes. A diameter≥80 mm is considered risk factor for reinterventions and target vessels instability is considered separately during follow-up.

Gallitto E ，Tsilimparis N ，Spath P ，Faggioli G ，Stana J ，Logiacco A ，Fernandez-Prendes C ，Pini R ，Rantner B ，Mascoli C ，Cappiello A ，Gargiulo M ... -  《-》

Association between diabetes status and long-term outcomes following open and endovascular repair of infrarenal abdominal aortic aneurysms.

Rastogi V ，Summers SP ，Yadavalli SD ，Perrier J ，Allievi S ，Jabbour G ，Stangenberg L ，de Bruin JL ，Jones D ，Ferran CJ ，Verhagen HJM ，Schermerhorn ML ... -  《-》

Comparison of EndoSuture vs fenestrated aortic aneurysm repair in treatment of abdominal aortic aneurysms with unfavorable neck anatomy.

Hostile aortic neck anatomy is associated with loss of proximal seal and increased late reinterventions. Although both EndoSuture aneurysm repair (ESAR) and fenestrated endovascular aortic repair (FEVAR) are commercially available options for treatment of short neck aneurysms, branch vessel patency is a potential tradeoff for improved seal with FEVAR owing to the incorporation of renovisceral vessels. This study compares the performance of ESAR vs FEVAR in hostile aortic necks. Patients who underwent elective ESAR or FEVAR for hostile neck AAAs at a single center from 2012 to 2024 were reviewed retrospectively. Exclusion criteria included pararenal or thoracoabdominal aortic aneurysm, off-label modifications, and nonstandard FEVAR configurations. Propensity matching weights were generated based on age, year of operation, preoperative estimated glomerular filtration rate, neck length, neck diameter, and infrarenal angulation. Rates of survival, reintervention, dialysis, chronic kidney disease stage progression, type IA endoleak (EL), and sac regression (>5 mm) were assessed at latest follow-up. Of 391 patients, 60 with ESAR and 207 with FEVAR were included. FEVAR patients were younger (74.4 years vs 79.8 years; P < .001) with larger neck diameters (25.0 mm vs 23.6 mm; P = .016), shorter neck length (5.0 mm vs 9.8 mm; P < .001), and decreased infrarenal angulation (20° vs 40°; P < .001). After propensity score-adjusted regression (58 ESAR, 169 FEVAR), FEVAR, compared with ESAR, was associated with decreased IA EL (hazard ratio, 0.341; 95% confidence interval [CI], 0.061-0.72; P = .031) and increased sac regression (hazard ratio, 3.92; 95% CI, 1.25-5.14; P = .02). Notably, FEVAR was associated with increased 1-year aneurysm-related reintervention (odds ratio, 4.33; 95% CI, 1.12-10.54; P = .046). On Kaplan-Meier analysis, FEVAR was associated with reduced freedom from reinterventions at 3 years (71.8% [95% CI, 0.63-0.78] vs 93.5% [95% CI, 0.80-0.97]; log-rank P = .019) but a trend toward improved survival at 3 years (79.15% [95% CI, 0.70-0.85] vs 61.5% [95% CI, 0.44-0.74]; log-rank P = .095). There was no significant difference in new-onset chronic dialysis between ESAR and FEVAR at 3 years (94.2% [95% CI, 0.82-0.98] vs 97.4% [95% CI, 0.93-0.99]; log-rank P = .124). In the treatment of abdominal aortic aneurysms with hostile neck anatomy in this propensity-matched cohort, FEVAR was associated with fewer type IA ELs and greater sac regression compared with ESAR, with no detrimental impact on long-term renal function. There were more reinterventions, mostly branch related, in the FEVAR group. We await the results of the current randomized prospective trial comparing these strategies to further determine the impact of these clinical differences on aneurysm-related mortality.

Fereydooni A ，Satam K ，Dossabhoy S ，Trogolo-Franco C ，Sorondo S ，Arya S ，Ullery BW ，Lee JT ... -  《-》